Sugar

Photo of the week

Highlight of the week: Virtual doctors deliver some trauma teaching and some solar lights for the clinic

Lowlight of the week: The following day, nobody turns up for round 2 of the trauma teaching

Maximum temperature: 42 degrees Celsius - it's a heat wave you know - actually it's just Africa

Rainfall: Fat chance

Sugar. Correctly enunciated: sugar is a cuss. But it is also a curse.

In Africa, the curse of type 1 diabetes is often less than sweet. Whilst type 2 diabetes will take years off a life. Type 1 diabetes has a short fuse and a bitter end.

My interest in sugar started in 1994. As a junior doctor, children and young people with diabetes captured me. I championed them and ended up in charge of the Paediatric diabetes unit at James Cook. As an endocrinologist I knew that the answer was in the hormones.

1994. The Dark Ages. Now that there is light, I look back at diabetes care then. Things were very dark. We did the best we could. With Dark Aged drugs. Dark Aged equipment. Dark Aged know-how. I couldn’t have imagined how care would be transformed in the years to come. In truth, I did imagine. But my thinking was very blue sky thinking. Insulin pumps. More responsive insulins. Continuous blood glucose monitoring. Testing blood glucose without a finger-prick blood test. My dreams were filled with tech. But within two decades I awoke to a cascade of technical dreams. Solutions to the nightmare of type 1 diabetes.

I ran the department. Held the baton for a while. We were early adopters. We liked tech. I empowered my diabetes specialist nurses. They were better at it than me. We ran a tight ship. With better control, comes quality of life. Less drama. Safer participation in sport. Young people have never had it so good. 

By 2015 the writing was on my wall. I had my fingers in too many other pies. So I opted out of diabetes. The tech was evolving too quickly for this particular pie maker. But I’ve always had a sweet spot for diabetes. 

Regular blog readers will know that our stroke prevention programme has a bee in its bonnet about type 2 diabetes - type 1 diabetes’ older, stockier sibling. Type 2 diabetes is from completely different stock. For the non-medics amongst you, this is where things may get a bit confusing. Diabetes is a collection of different problems. They all cause high blood glucose and eventual poor health. But the root cause of type 1 and type 2 diabetes are poles apart. A different starter for 10, you might say.

Our stroke programme seeks out older people with Type 2 diabetes. A condition linked with lifestyle choices and some genetics. Most of our older people with diabetes have a generous waist. They sit too much and move too little. A diet high in refined carbohydrates lends a helping hand. All of this leads to an excess of insulin. Produced in a pancreas that is working at full pelt. The opposite of what happens in type 1 diabetes.

The mainstay of treatment for type 2 diabetes is to change lifestyles. Eating patterns. Activity. Lifestyle is key, but we also use a wonderful drug called metformin. Eighty five percent of Type 2 diabetes can go into remission. But of course patient and doctor need to be singing from the same hymn sheet. And the hymn sheet needs to be credible, with all the notes in the right order.

My own expertise is in Type 1 diabetes. In Type 1 diabetes the body stops making insulin. Life without insulin is near impossible. Insulin has to be given by injection. Type 1 diabetes is tricky to manage. Requiring a lifelong personal commitment to stay healthy. Together with family and professional support. Type 1 diabetes will never go away. It affects younger people. Often in their teens. But many are even younger than that. I’ve even looked after a baby who was born with it. Weighing in at 1 kg, my patient was born without insulin. The  weight of a bag of sugar, and just as sweet. He turned 18 last week. His mum messaged me to prod my grey cells. I remember the challenge and the joy of our successes as if it was yesterday. It was my pleasure to look after the smallest baby ever to be given an insulin pump.

Welcome back to present day Zambia. In the middle of deepest darkest Africa. I’m in clinic. This is 2 weeks ago. I am working with Spiwe, one of our experienced nurses. Selina comes through the door. The 19 year old patient has come alone. Her symptoms are straight out of a diabetes textbook. Thirst. Weight loss. No energy. Passing urine 5 times a night. And lots during the day. Spiwe and I send Selina to the lab, but already know what is coming. Her urine is full of sugar and ketones. Her blood sugar is 23. She is young. Slim. And without a doubt has type 1 diabetes. In the UK, this would prompt an immediate referral to hospital. She needs insulin.

Spiwe and I share the difficult news with Selina. You must be started on insulin, in hospital, Selina. Kamoto hospital is 60 km away. The trip is Selina’s first, of many, hurdles. I will need to go home and tell my family. I hope they can find the money to take me. I wince. And turn the thumbscrews: You must get there today, or tomorrow at the latest.

By chance, that afternoon, I discover that Selina is known to one of the youth programmes in Mfuwe. She is a bright girl. Undertaking a preparation for life course. With the hope of going on to further education. University. And beyond. Through the youth programme I get her phone number. And follow her progress.

Monday morning comes. I get a message. Selina is at home. She went to the hospital on Friday. They discharged her with tablets. My heart lurches. Oh no. It is now 4 days since I saw her. On Thursday she had urgently needed insulin. My referral letter was quite clear about that. How could they possibly mix things up? How could they mistake Selina’s problem as late onset Type 2 diabetes? Selina’s life is hanging by a thread.

I contact our boss up at the District Medical Office. I ask Dr George if insulin is available. I tell him the story. I tell him that Selina will die without insulin. Dr George jumps to Selina’s rescue. He sorts out a doctor to see Selina straight away. We arrange for her immediate return to hospital. Selina’s life is saved by the magic of insulin. From a bottle. Given via a needle. Modern medicine. Given in the middle of this dark continent. After a battle.

After winning one battle we realise that the war has only just begun. Selina is living in a country that does not have diabetes specialist nurses. Zambia barely has insulin. Never mind all the highfalutin tech that we are used to using in the UK. Selina is going to need a few more nudges and a fair amount of help from me. I can feel a new crusade coming on.

I travel in time. Back to 1994. To the foundation of my diabetes care-giving. My original dark ages. Now in 2024, the darkness reemerges. My knowledge and experience of providing care with rudimentary insulins and equipment will again allow me to guide Selina and her carers. I am back to using old style basic insulin. Injecting with needles and syringes. Testing with finger pricks.

With luck Selina will be given insulin by the Zambian health service. But everything else needed for her care has a price tag. The family have no fridge. Her insulin must be kept cold. Selina’s regime is a bit odd. I plan to do some meddling. My job here is to educate. Teach. Support. Mentor.

Without my help, Selina will probably stay alive. But she will likely have poor vision and kidney impairment within 10 years. My aim is to help her to manage her diabetes. I want to do the best we possibly can for her. I want her to stay healthy and to have a bright future.

This Thursday Selina and I meet. Happily there is no language barrier. Her English is immaculate. We start with the basics. I draw pictures. I am not the best artist in the world. But even my diagrams help. I provide information. She listens and interjects. Clearly understanding. Questions flow both ways. I need to understand more about her culture. Her eating patterns. Her activity levels.

Selina’s questions centre on the diabetes. Why? What have I done wrong? Will it ever go away? We have about an hour together. That is more than enough. I wish I had written material. She only has a small phone. So no internet access. We make a plan. For insulin doses. Times to test her blood sugar.

On the practical side we have some major hurdles: Selina only has 2 syringes left. She is paying 10 Kwacha (30p) for each blood sugar test. She won’t be able to test 4 times per day, or to inject more than twice a day. She will have to reuse her needles. There is no HIV or hepatitis risk, but blunted needles are unpleasant and can cause infection. Selina’s insulin is currently kept in the fridge at the clinic. A good 20 minute walk away from her house. Two trips to the clinic every day is not sustainable. Everywhere we look, we see problems.

But Selina is resourceful. She is accepting. She tells me: I will just have to get on with it. Do my best. We arrange to meet after a week. I have 4 weeks left now to pass over as much help as I can. Our list of troubles to shoot is long:

I gift Selina a box of 100 syringes and needles. She can have our blood glucose meter when we leave. And hopefully a load of test strips too.

A fridge at home without solar power will not work. The power cuts here are too frequent.  Too long. The insulin will stay at the clinic for now.

WhatsApp will help us to keep in touch. If she can afford the data bundles.

The curse of diabetes has left Selina and I thirsty for solutions. For now, I will subsidise where I can. But I hope that sponsorship from donations will support her towards a bright future. With her positive attitude, resilience and drive to succeed I hazard she has a better chance than most people in Zambia to do well.

Thank goodness he's well fed

A new push for HIV testing in our tree clinic

Trauma teaching from Virtual Doctors